OPINION: UHN’s Award in Transplant Innovation Obscures Two Deeper Challenges: Organ Donation and Technology Commercialization

By Ross Wallace, Principal at Santis Health

The Toronto Star recently published an important and compelling article marking the news that Toronto’s University Health Network (UHN) was now North America’s largest adult organ transplant program.  UHN performed 639 transplants last year, besting California counterparts at UCLA Medical Center and the University of California San Francisco Medical Center.

UHN’s accomplishment can be attributed to two distinct but interrelated factors:  an unparalleled transplant team, led by Dr. Atul Humar (lead of the Multi-Organ Transplant Program at UHN) and Dr. Shaf Keshavjee (UHN’s surgeon-in-chief) and a cutting-edge technology platform which was developed by UHN itself.

The “Toronto Ex Vivo Lung Perfusion System” (Toronto EVLP) allows lungs to be preserved outside the body for up to 24 hours and dramatically increasing the number of organs available to patients – leading to a transformational change in UHN’s approach to organ transplantation.  The impact of organ perfusion is already being felt well beyond the borders of UHN, as seen in the American Society of Transplantation’s decision to recognize the system with its AST Innovation Award.

Although UHN deserves serious kudos as this continent’s leading transplant centre, the Star’s article misses two key elements to the story that deserve a deeper dive.  First, the challenges impeding Canada’ goal of creating a new generation of global biomedical companies; and second, the challenge to Canadian’s health care system of insufficient organ donation.

Let’s look at commercialization first: the Toronto EVLP System is being commercialized by XOR Labs, a start-up company spun out of UHN.  Despite the cutting-edge technology and the global market opportunity – XOR estimates many thousands of patients around the world could benefit from a lung transplant – XOR remains relatively invisible to the broader public.  Although Toronto is home to many of Canada’s most technologically advanced medtech companies, companies like XOR need more sources of early-stage capital.  That’s why there’s so much interest in the $50M joint Ontario-Quebec life sciences venture fund recently announced in both provinces’ budgets, but this amount only scratches the surface of the need faced by XOR and its peers.

Shifting to the health system, the supply of donated organs continues to dramatically lag demand.  According to the Canadian Institute for Health Information (CIHI), there were 758 deceased donors in Canada in 2016 – or 20.9 donors per million population.  Although the donor rate has increased by 42% in the last decade, there are still more than 4300 Canadians on the wait lists for kidney, liver, heart or lung transplants.  And polling data shows more than though 90% of Canadians support organ donation, only about 20% have consented to donate.  Ex vivo organ perfusion is groundbreaking technology, but its impact is still being felt at the margins of a problem that requires a change in behaviour from thousands of individual Canadians.

One recent cause for optimism actually stems from the tragic accident that claimed the lives of 16 members of the Humboldt Broncos hockey players.  One of the players who died was Logan Boulet, whose donated organs found their way into six other Canadians in dire need of transplants – and whose inspiring and generous example has caused organ donation registration to spike across the country in response.

UHN should be justifiably proud of not only its spot at the top of the continent’s list of top transplant teams but also the impressiveness of its innovation.  I’m looking forward to the day when the Network can be equally proud of the emerging superstar medtech company taking that same technology into the world, and maximizing the impact of the live-saving decisions made by Logan Boulet and those he inspires.

Former PC policy advisor Emily Beduz joins Santis Health as Consultant

Toronto, ON – April 6, 2018 – Santis Health is pleased to announce that former Progressive Conservative staffer Emily Beduz has joined the Santis team as a Consultant.

For more than three years, Emily was the policy advisor on health to the PC leader, working closely with the critic’s office and advising caucus on health policy matters. Prior to Queen’s Park, she also spent time working in live TV production at Sun Media and for the Mayor of the City of Toronto.

Emily brings to Santis her effective research skills, a strong understanding of municipal and provincial politics, and strong, productive relationships with stakeholders and Members of Provincial Parliament across party lines.

Santis Health is a Toronto- and Ottawa-based public affairs, strategic advisory, public policy, marketing and communication consultancy that is dedicated to providing first-class counsel and support for clients exclusively in the health care and life sciences sectors.


For more information, contact Gemma Villanueva, Public Affairs Coordinator at Santis Health.

email: gemma.villanueva@santishealth.ca
phone: (647) 776-8010 ext. 4007

Link to Emily Beduz’s bio on our website:
http://santishealth.ca/bios/emily-beduz ‎

Premier Kathleen Wynne shuffles cabinet

On January 17, 2017, Premier Kathleen Wynne shuffled cabinet to fill vacancies left by current ministers Brad Duguid, Liz Sandals and Deb Matthews who are not running for re-election in June.

Along with the shuffling of six current ministers, Wynne’s cabinet includes three new backbenchers including Harinder Malhi (Minister of the Status of Women), Nathalie Des Rosiers (Minister of Natural Resources and Forestry) and Daiene Vernile (Minister of Tourism, Culture and Sport).

Some major changes include Deb Matthews’ replacements. Helena Jaczek (Minister of Community and Social Services) will replace Matthews as Chair of Cabinet and Mitzie Hunter will now assume the role of Minister of Advanced Education and Skills Development. The position of Deputy Minister is now vacant.

Eric Hoskins remains as the Minister of Health and Long-Term Care. Bob Bell also remains as Deputy Minister of Health and Long-Term Care.

With these changes, Wynne’s cabinet closes in on the gender balance, with 13 women, including the Premier, and 16 men.

New Ministers include:

  • Harinder Malhi (Brampton-Springdale) becomes Minister of the Status of Women, which had been part of Indira Naidoo-Harris’ duties;
  • Nathalie Des Rosiers (Ottawa-Vanier), will replace Kathryn McGarry as Minister of Natural Resources and Forestry;
  • Daiene Vernile (Kitchener-Centre), succeeds Eleanor McMahon as minister of tourism, culture and sport.

Ministers promoted within cabinet include:

  • Indira Naidoo-Harris (Halton), who becomes Education Minister as well as continuing as Minister for Early Years and Child Care;
  • Steven Del Duca (Vaughan), who transfers from Transportation to Duguid’s former post at Economic Development and Growth;
  • Eleanor McMahon (Burlington), who succeeds Sandals as President of the Treasury Board after serving as Minister of Tourism, Culture and Sport;
  • Kathryn McGarry (Cambridge), who was Minister of Natural Resources, moves to Transportation;
  • Mitzie Hunter (Scarborough-Guildwood), replaces Matthews as Minister of Advanced Education and Skills Development;
  • Helena Jaczek (Oak Ridges-Markham), assumes Matthews’ responsibilities as Chair of Cabinet.

Auditor General of Ontario’s health care observations

On December 6, 2017 the Auditor General of Ontario, Bonnie Lysyk, released her 2017 Annual Report. The report dedicates five of the 14 value-for-money audits to health care issues including cancer treatment services, community health centres, laboratory services, public drug programs and chronic disease prevention. The audit also focused on emergency management and its impact on public health and safety.

The Minister of Health and Long-Term Care released the following statement in response to the audit.

The following summary highlights the Auditor General’s key observations in each topic.

Section 3.02 – Cancer treatment services  
The audit found that the Ministry of Health and Long-Term Care (MOHLTC), Cancer Care Ontario (CCO) and hospitals generally provide cancer treatment in a timely, equitable and cost-effective manner for most patients, but not all. Some cancer services are not provided in manner that meets the needs of Ontarians. For example:

  • There are significant regional variations in wait times for some urgent cancer surgeries.
  • Some radiation treatment plans are not reviewed according to clinical guidelines.
  • Radiation treatment is under-utilized.
  • Inequities exist in access to take-home cancer drugs.
  • Supports are inadequate for patients on proper and safe usage of take-home cancer drugs.
  • No oversight of cancer drug therapy is provided at private specialty clinics.
  • Stem cell transplant wait times are long.
  • There is insufficient capacity for stem cell transplants.
  • Symptom-management support is inadequate.
  • Psychosocial cancer services are insufficient and inconsistent.
  • Ontario is slow to adopt advances in positron emission tomography (PET) scans.
  • Significant regional variations exist in CT scan and MRI wait times for cancer patients.
  • Wait times for biopsies are long.
  • There is no provincial peer review program for diagnostic-imaging results.
  • Cancer funding is inequitable.

To read the cancer treatment services audit in depth click here.

Section 3.03 – Community health centres
The Auditor General found that Ontario’s 75 Community Health Centre’s (CHC) provide health care and community programs to vulnerable populations and can contribute to reducing the strain on the health care system and other provincial government programs. However, the audit concluded that the MOHLTC and the Local Health Integration Networks (LHINs) do not have sufficient information to ensure that CHCs deliver programs and services in a timely and cost-effective manner that meet the needs of their target population groups. Other observations include:

  • Split responsibility between Ministry and LHINs on primary care in the last decade is not conducive to effective primary-care planning.
  • Utilization of CHC services varies across the province.
  • Inter-professional primary care is not available in all LHIN sub-regions in Ontario.
  • CHC staffing model and types of services have not been defined.
  • Funding to CHCs is not tied to number of clients served.
  • LHINs do not sufficiently monitor CHCs.
  • Meaningful data is not collected to evaluate effectiveness of CHCs.

To read the community health centres audit in depth click here.  

Section 3.07 – Laboratory services in the health sector
The audit found that laboratory services are generally provided safely and accurate laboratory test results and generally provided to health care professionals in a timely manner. Despite this, the audit found that several areas relating to cost-effectiveness, accessibility, and performance measurement and reporting of laboratory services need improvement. Observations include:

 Cost to the Ministry and to patients:

  • Outdated laboratory test price list resulted in overpayments to community laboratory service providers.
  • Price list not updated using all relevant cost data.
  • Medically necessary tests remain uninsured.
  • More action needed to reduce unnecessary testing.
  • Inadequate strategy for genetic testing results in costly out-of-country testing.
  • More effort needed to identify and improve underserved areas of laboratory services.

Regional inequities:

  • Inadequate strategy for genetic testing results in costly out-of-country testing.
  • More effort needed to identify and improve underserved areas of laboratory services.

Ontario’s laboratories’ performance:

  • Limited investigation of large in-office laboratory test volumes and billings by physicians.
  • No licensing and quality management of physicians’ in-office laboratory testing.
  • Lack of regional co-ordination and integration of hospital laboratories.
  • No oversight of billing practices by hospital laboratories.
  • No consistent performance measurement and reporting of laboratory services.
  • No provincial target, data collection and monitoring of wait times for laboratory services.
  • No assessment of the effectiveness and efficiency of laboratory service providers by Ministry.
  • Inadequate oversight of quality management program. 

To read the laboratory services audit in depth click here.

Section 3.09 – Ontario public drug programs
The audit made the following observations on Ontario public drug programs:

Brand name drugs:

  • Negotiations for brand-name drugs have led to significant rebates from drug manufacturers, but it is difficult to know whether the Ministry is obtaining the best possible value compared to other jurisdictions.
  • The processing of rebates for brand-name drugs is too slow and prone to error.

Generic drugs:

  • Generic drug prices in Ontario have dropped significantly in the last 10 years, but the Province still pays more than foreign countries.
  • The Ministry paid significantly higher amounts for a number of commonly used generic drugs than some Ontario hospitals.

Exceptional Access Program:

  • Many patients requesting exceptional drug coverage waited excessively.
  • The Ministry has acknowledged weaknesses in processing exceptional access requests since 2010.

Oversight of payments to pharmacies:

  • The Ministry did not inspect and/ or recover many payments for invalid claims, leading to about $3.9 million of inappropriate payments.
  • The Ministry did not refer several potentially fraudulent billings to the Ontario Provincial Police (OPP) in a timely manner.

MedCheck program

  • The Ministry does not know if the MedsCheck program ($550 million between 2008/09 and 2016/17) is effective.

Opioid crisis

  • Despite numerous initiatives taken by the Ministry in dealing with the recent opioid crisis in the province, it does not have the critical information needed to inform its decisions in addressing the issues. 

To read the public drugs programs audit in depth click here.

Section 3.10 – Public health: Chronic disease prevention
The audit found that public health units’ performance in chronic disease prevention is not measured fully by the MOHLTC. Other observations include: 

  • Ontario has no overarching chronic disease prevention strategy.
  • Some public health units faced challenges in accessing schools to provide health promotion programs.
  • No consistent provincial leadership to co-ordinate public health units’ updating of evidence, sharing of best practices, and development of monitoring systems on health promotion programs.
  • Not all public health units have access to necessary epidemiological data.
  • Public health units individually indicated that they have limited capacity to perform epidemiological analysis to help guide and monitor their programs.
  • At some public health units, program evaluations were not conducted to determine whether their programs had a positive impact.
  • Current provincial performance indicators do not fully measure public health units’ performance in preventing chronic diseases and promoting health.
  • Ministry has started to address funding equity but full implementation of the needs-based funding model may take up to 10 years.

To read the chronic disease prevention audit in depth click here.

Section 3.04 – Emergency management in Ontario
The audit found The Provincial Emergency Management Office (EMO) and the selected ministries need to improve their policies and procedures to ensure that fully effective emergency management programs would be able to respond quickly if needed to protect the public and sustain provincial and municipal operations.

Additionally, EMO needs to better co-ordinate the provincial emergency management program by providing tools and resources to ministries and municipalities. EMO and the ministries also did not have effective processes to measure, evaluate and publicly report on the emergency management program’s objectives. In addition, we found that emergency management operations at EMO and the ministries, including the disaster financial assistance programs, are not always carried out with due regard for economy and efficiency. The audit found:

  • The current governance structure for emergency management in Ontario is not effective for overseeing a province-wide program.
  • Lower than expected priority given to emergency management.
  • Risk identification and assessment processes are not sufficient to ensure that the provincial emergency management program includes all areas of concern.
  • The Province does not have a co-ordinated information technology (IT) system in place for emergency management.
  • The provincial emergency management program does not focus on all five components of emergency management: prevention, mitigation, preparedness, response and recovery.
  • Emergency response plans have not been updated to reflect current events or operations.
  • The approach to practicing for emergencies does not ensure that the Province is prepared to respond to emergencies.
  • The Province’s overall state of readiness to respond to emergencies needs significant improvement.

The audit noted the following concerns with regard to Ontario’s state of readiness:

  • Numbers of trained staff are not sufficient for a lengthy emergency.
  • A standardized approach for emergency response has not been mandated after eight years in development.
  • Agreements are not in place for resources that may be needed in an emergency response.

To read the emergency management audit in depth click here.

Health care commitments from the newly-released Ontario PC platform

On Saturday, November 25, Patrick Brown released his political platform for the 2018 provincial election titled “The People’s guarantee.” The People’s guarantee highlights five key commitments including the “largest mental health commitment in Canadian provincial history.” The following summary was lifted from the document released on the weekend.

Regarding health care, Patrick Brown and the Ontario PCs will:

  • Commit $1.9 billion to build a comprehensive mental health system which is the largest mental health commitment in Canadian provincial history.
  • Reduce hospital and emergency room wait times.
  • Create a dental program for low-income seniors.
  • Build 15,000 new long-term care beds in five years and 30,000 over 10 years.
  • Treat doctors with respect by always consulting them on future reforms to the healthcare system as well as protecting their conscience rights.

 Mental health
The federal government made a 10-year, $1.9 billion commitment to mental health in Ontario as part of their most recent health transfer agreement with the province. Patrick Brown and the Ontario PCs will match that 10-year federal commitment, with the goal of creating a comprehensive mental health treatment system in Ontario.

Patrick Brown will make it his government’s priority to devise a comprehensive mental health system that would include building on existing investments in mental health. The funding will be directed towards priorities including:

  • Targeted investments into youth and children’s mental health services across the province to reduce wait times for services, including funding for mental health support services at Ontario’s college and university campuses.
  • Expanding the Crisis Outreach and Support Team (COAST) pilot project, which teams up plain clothes police officers and mental health workers to divert people in crisis away from repeated police contact.
  • Investing in mental health services, including suicide prevention counselling. This will include services for Indigenous populations through a preventative mental health team that that specifically deals with Indigenous and Northern communities, instead of sending crisis reams to places like Attawapiskat only after a crisis has occurred.
  • Topping up elementary and secondary school supports for services targeted at improving mental health and well-being, including funding awareness campaigns.
  • Reforming existing post-traumatic stress disorder (PTSD) legislation to presume PTSD diagnoses for trauma nurses are workplace related.
  • Investing in the Alzheimer Society of Canada’s First Link program to help people diagnosed with dementia get the support and treatment they need
  • Addressing security issues at Waypoint Centre for Mental Healthcare
  • Investing in data collection regarding mental health, addictions, and treatment to identify and fill gaps in care.
  • Increasing the budgets of Ontario’s designated psychiatric facilities to increase the capacity and reduce wait times.
  • Funding more in-house Behavioural Supports Ontario (BSO) teams in long-term care homes as well as more housing supports for those dealing with mental health issues.

Hospital wait times
Patrick Brown and the Ontario PCs will make proper investments in other parts of the health care system to alleviate the pressure on hospital emergency departments.

Dental program
Creating a dental program for low-income seniors will go a long way to relieving these pressures and reducing hospital wait times. To facilitate this, the government should invest in two initiatives:

  1. The government should provide funding for dental capacity in Public Health units, Community Health Centres and Aboriginal Health Access Centres.
  2. The government should invest in new dental services in underserviced This includes working with the public and private sector and investing in mobile dental busses to help Ontario’s senior in more rural locations.

Combined, these two investments could treat as many as 90,000 – 100,000 low-income seniors a year.

Long-term beds
Hospitals are becoming overcrowded, patients are being treated in hallways and temporary patient rooms, and hospitals can’t keep up. These pressures stem from the lack of long-term care beds in the province, with more than 32,000 seniors on the waiting list for long-term care bed in Ontario.

Treat doctors with respect
There should be an independent process for medically assisted dying that works effectively for patients that is not punitive for providers, and that does not force participation of a provider where they are unwilling to participate. In addition, access to a family doctor is still a concern for many Ontarians, particularly in rural and Northern Ontario, while access to specialists is a concern across the province. Patrick Brown and the Ontario PCs will appoint a task force to study access shortages to family doctors and specialists across the province.

Opioid crisis
The Liberal government recently took a good first step in appointing a task force to combat the spread of opioids. However, more can be done, such as:

  • Banning pill presses used to make opioids unless used by a professional, such as a pharmacist.
  • Ensuring that local law enforcement and health officials are on the same page when it comes to interacting with people with addiction issues and mandate that a health representative is put on local police boards.
  • An advertisement campaign about the dangers of opioids, funded by the province using the newly committed dollars for mental health services

Oral cancer drugs
By funding take-home oral cancer drugs, we can allow patients, if they choose, to receive treatment in the comfort of their own home and divert patients away from hospitals, freeing up needed resources and space at the hospital level.

Clinical trials
Patrick Brown and the Ontario PCs will allow patients participating in clinical trials to be eligible for publicly funded treatment following the end of their clinical trial.

Cardiac care centres
When it comes to treating coronary artery disease there are only 19 hospitals in Ontario that provide advanced cardiac services. The province should review the current gaps in care and fund the building of new centres to help improve services in other regions.

Patrick Brown and the Ontario PCs will restore the $50 million cut from seniors’ preventative therapy services budget for services such a physiotherapy.

Assistive Devices Program
Patrick Brown and the PCs will undertake a review of the lists of devices covered by the Assistive Devices Program, shorten administrative payment timelines and increase the government’s coverage to 80% of listed items.

Childhood obesity
In 2014, the government initiated a pilot program of 60 minutes of daily exercise in public schools instead of the current 45-minute minimum requirement. This initiative deserves to be made mandatory for all schools.

Renewing health cards
Patrick Brown and the PCs will create an online portal for renewing health cards.

Contraband tobacco
Patrick Brown and the Ontario PCs will expand the Provincial OPP Enforcement Team to combat contraband tobacco to include local police forces and give those forces the necessary tools to fight contraband tobacco.

Personal support workers
Patrick Brown and the Ontario PCs will allow the Ontario Personal Support Worker Association (OPSWA) to run the central registry for personal support workers instead of a government body.

Administration costs
Patrick Brown and the Ontario PCs will work with the home care sector to ensure resources go towards high quality patient care, not administrative costs.

Traditional Chinese Medicine
Patrick Brown will commit to allowing Traditional Chinese Medicine exams to be written in commonly accepted Chinese languages.

Patrick Brown will honour previous promises made by the government, including the pharmacare program OHIP+ which provides free medication to youth aged 24 and under. Patrick Brown and the Ontario PCs will also review the province’s drug programs, including ways to increase support for rare disease coverage.

Frontline health care
Patrick Brown and the Ontario PCs’ health care promises will total an additional $1.6 billion by the end of the mandate into frontline health care.

Federal cabinet shuffle sees Petitpas Taylor in Health, Philpott moves to Indigenous Services

Prime Minister Justin Trudeau shuffled his cabinet and made significant changes that impact the Health portfolio as announced at 12:30 p.m. at Rideau Hall in Ottawa this afternoon. MP Ginette Petitpas Taylor, currently Parliamentary Secretary to the Minister of Finance, becomes the new federal health minister while the Hon. Jane Philpott becomes Minister of Indigenous Services.

Liberal MP Ginette Petitpas Taylor was elected in October 2015 as a MP in the riding of Moncton–Riverview–Dieppe. She served as the Deputy Government Whip from December 2015 to January 2017. In January 2017, she was named Parliamentary Secretary to the Minister of Finance.

Minister Petitpas Taylor holds a bachelor’s degree in social work from the Université de Moncton. She served 23 years as Victims Services Coordinator with Codiac RCMP, where her responsibilities included crisis counselling, domestic violence intervention, and domestic violence risk assessment to victims of crime.

A dedicated volunteer, she supports several community organizations at both provincial and local levels, including the Coalition Against Abuse in Relationships and the Canadian Mental Health Association’s Suicide Prevention Committee in Moncton.

To address the growing concern about Indigenous health outcomes, Indigenous and Northern Affairs will be split into two departments. Former health minister Jane Philpott takes on a new role with responsibilities for Indigenous Services, while the Hon. Carolyn Bennett will remain as part of the reconfigured department handling treaty issues as Minister of Crown-Indigenous Relations and Northern Affairs.

Other moves in the cabinet shuffle include:

  • Kent Hehr, Minister of Sport and People with Disabilities (previously Minister of Veteran Affairs and Associate Minister of National Defence)
  • Seamus O’Regan, Minister of Veterans Affairs and Associate Minister of National Defence
  • Carla Qualtrough, Minister of Public Services and Procurement (previously Minister of Sport and Persons with Disabilities)

OPINION: Lower drug prices ahead, but at what cost?

By Jason Grier, Principal at Santis Health

Will the current drive for lower patented drug prices be the next thing to prove the old adage “if something is too good to be true, it probably is”?  The answer is, we won’t really know until we consider the possible trade-offs associated with current policy initiatives to try to further use regulatory instruments to push prices lower.

Last month, Health Canada opened a brief consultation window on the Patented Medicines Regulations, which play an important role in drug price regulations in Canada.  These regulations govern the requirements which manufacturers of patented medicines must follow when it comes to supplying pricing information to the Patented Medicine Prices Review Board (PMRPB)

The PMPRB was established thirty years ago as an independent, quasi-judicial agency with a mandate to protect consumers from excessive pricing by setting the maximum price at which a patented drug can be sold in Canada.   In doing so, the PMPRB has relied on comparative pricing data of other drugs in the same therapeutic class within Canada, as well as pricing data in seven other countries (the “PMPRB7”).

The proposed amendments come on the heels of an earlier consultation process led by the PMPRB itself and are clearly designed to further lower drug prices in Canada.  In support of Health Canada’s decision to seek input on the proposed changes, it noted that the regulations had not been changed in twenty years.

But what is the evidence that a change is necessary – or is this simply change for the sake of change?  Interestingly, the PMPRB’s own data shows that Canada sits in the bottom third of the PRMPRB7 when it comes to the prices of new medicines and that our prices in 2015 had already dropped to 18% below the median average of comparator countries.  This begs a natural follow-up question:  if the Board is successfully over-delivering on its mandate, than what exactly is driving this urgency for change?

Notwithstanding Canada’s success at achieving lower prices than comparable jurisdictions for patented medicines, government has signalled that it wants to go much, much further.  These proposed changes are expected to do just that, perhaps driving maximum prices down by a further 20% or more, according to industry estimates.

From the perspective of both public and private payors, as well as patients, lower drug prices must certainly appear very attractive.  What could possibly be wrong with wanting lower drug costs for Canadians? As is so often the case in health care, however, policy makers must be wary of any unintended consequences of each policy decision they consider.   While lower drug prices on their own may certainly appear attractive, it is important to weigh the negative impacts that lower drug prices may also bring.

In this case, the principal impact may be a reduction in Canadians’ access to future drug innovations.  By reducing drug prices further, the market viability of certain new drugs may be compromised, reducing the likelihood that new therapies will come to Canada in a timely fashion – or at all.

Simply put, Canadians may increasingly find that drugs available in US or European markets simply aren’t for sale here because the economics of seeking Health Canada approval and marketing a new drug are no longer sufficient to justify the cost.  We can see evidence of this type of decision making already when we look at head-to-head comparisons with some of the countries newly proposed as PMPRB comparators (e.g. Korea, Japan, Australia).  In each case, far fewer than half of new drugs are made available to patients in those countries (source: PMPRB), whereas 61% of those products were available in Canada.

In addition to the possibility of fewer new drugs, there may be other impacts as well. Canada’s public drug plans claim to have achieved significant savings over pharmaceutical list prices by working through the pan-Canadian Pharmaceutical Alliance (PCPA) to secure confidential listing agreements with manufacturers. The ability to secure favourable arrangements specific to public payors may be compromised by lowering the maximum price paid by all classes of payors and by eroding the expectation of confidentiality around these listing agreements.  These moves will also send a message to pharmaceutical companies around the world that Canada now places a lower value on their innovative products.  In the very month that Canadian ministers representing four provinces paid visits to the BIO2017 conference in San Diego to attract investments from the global pharmaceutical community, this seems a contradictory message to send.

Should we care?  On balance, the benefits of these changes could outweigh the risks.  But before we can know that, government must take the steps to properly review not only the benefits of lower drug costs, but also all of the potential consequences of pursuing such a policy. These decisions need to be made within the context of a clear vision of how all Canadians view the importance of access to new and innovative medicines as a component of a high performing health care system.


OPINION: Patients First – A New Mindset

By Janine Hopkins, Principal at Santis Health

The topic of health system reform is typically met with cautious optimism at best and simmering frustration at worst.  Despite the many reasons for skepticism, I believe that Ontario’s current health reform gambit, Patients First, has the potential to bring about lasting – and even transformational – system change.

I’m sure that some readers have already concluded that I drank the Kool-Aid and are preparing for an onslaught of talking points. However, I’m not a cheerleader for Ontario’s latest reform effort – or any other particular strategies.  What I have is a unique vantage point, having served as an advisor to a former Ontario Minister of Health and Long-Term Care when many underpinnings of Patients First – including LHINs – were introduced, and through executive roles in the broader health sector, at the Toronto-Central LHIN and now as a consultant helping clients keep up with the changes underway.

Patients First is the latest chapter in a transformation strategy that began in the first days of the McGuinty government and arguably even earlier, during the upbeat days of the Romanow Commission.  Every jurisdiction with an aging population faces similar challenges. All have some kind of plan – and every plan has flaws. Every attempt to disrupt the status quo is met with resistance.  Health care is political and always will be.

If we are to fundamentally fix what’s broken and, ultimately, deliver better results to patients and the public, this will have less to do with policy prescriptions and structures and more to do with mindset and leadership.  In other words, it’s better to think of Patients First as a plan, not a solution.  What matters is what we do, individually and collectively.

Why am I optimistic about Patients First?  As a start, there are at least three things in it that everyone seems to agree on:

First, stakeholders acknowledge that the system has been designed around the interests of providers and that we need to turn this on its head so we begin and end with patients and communities.

I’ve never heard anyone disagree that patients and caregivers need to be true partners in their care.  We need to keep getting better at patient engagement. We are starting to measure and speak honestly about health inequities and efforts to co-design services with patients and caregivers show that were making meaningful progress here.  Could Patients First be a lever to tackle health equity and achieve a real impact on indigenous health?

Second, there’s lots of head nodding about the need for integration.

Ontario’s health system is too confusing and disorganized.  It’s not as efficient as it could be and, as a result, we end up squandering resources and talent.  Ontario needs to continue to move away from compartmentalizing services and toward a system where collaboration is the norm.  The move to sub-regions – where all providers are accountable for the same outcomes for people in their area – has the potential to be a game changer.  It will take enormous hard work and perseverance to integrate primary care, public health and the other large pieces of the system.  While we are taking this on, we need to recognize that fast-growing areas of health care are only tangential parts of the health care ecosystem – eye care, drugs, and retirement homes, for example, are rarely part of LHIN planning tables.  Does this need to change?

Third, Patients First marks an important step in better aligning public health and the LHINs.

It’s well accepted that strong, integrated primary and community care is the foundation of a person-centred and affordable health system. It makes sense that this is the centerpiece of Patients First.  Everyone understands that people’s health is influenced more by education, housing and other social determinants than what goes on in the health system. Of course, the big play is tackling the social determinants through a wholesale commitment to healthy public policy and prevention.

So, how do we move from planning to doing?  Here are five modest proposals:

1 – Let’s build on what’s working. For example, Health Links and now sub-regions are enabling providers to tackle problems differently.  There is still competition, naturally, but there’s also a growing realization that the greatest returns come from working together for patients.  The acceleration of voluntary integrations of health service providers is a symptom of this new mindset.

2 – Avoid believing that restructuring is the answer. I’m not going to weigh in on whether the CCAC-LHIN merger is necessary, but we can all agree that it’s not sufficient. It will be a major undertaking and careful execution is crucial to ensure continuity of care.  But the LHIN-CCAC merger is one means to an end.  The government and LHINs need to be clear about how the structural changes lead the transformation of care delivery.  They need to be able to simply and convincingly answer questions like “What will be different for the 86-year-old woman in rural Ontario who just lost her spouse, has no caregivers, is deeply depressed, and struggling to cope?”

3 – Don’t spend energy worrying about what “sectors” play what roles. Everyone needs to be flexible.  Every part of the system has its strengths and lines are blurring – the reality is that hospitals have much bigger budgets, better infrastructure, and have been able to invest in management expertise.  Community and home care agencies have deep knowledge of their communities and are experts in caring for the entire family. Volunteers are part of the lifeblood of community health organizations and hospitals alike.  Once strengths are understood and respected, they can be leveraged for everyone’s benefit.

4 – Involve front-line staff at every step. The real transformation happens at the point of care – in a family home, a community clinic, or bedside in a hospice.

5 – Opt for more accountability and less top-down control. The LHINs have been tasked with leading system transformation.  They need more freedom to lead.  The sub-regions are a golden opportunity to bring in different perspectives. Without new voices and leadership renewal, Patients First will get stuck in the echo chamber.

Optimism is necessary because fear-induced change won’t last.  If fewer organizations say “We are doing this before it’s done to us” and more say “We are choosing to change because we can do better for patients,” we’ll know the mindset has shifted.

Five Things to Look for in Tomorrow’s “Health Budget”

By Dan Carbin, Principal at Santis Health

Tomorrow, Ontario Finance Minister Charles Sousa will table the government’s penultimate budget before the next provincial election in June 2018. While the 2018 budget is widely expected to include a host of new spending commitments and dovetail with the Liberal Party’s re-election sales pitch, the 2017 budget is shaping up to be more defensively minded and focused squarely on neutralizing health care as a potential electoral liability in 2018.

In recent months, the government has come under increasing scrutiny for its handling of the health file. Hospitals have been warning with increasing resonance that years of sub-inflationary investment is leading to ER backlogs, stretchers in hallways and over-crowded wards. Doctors are engaged in a divisive and prolonged dispute with the government over fees. CCACs in some areas of the province have been forced to dramatically increase home care wait lists in response to surging demand and constrained budgets. Patients are complaining to the media about cancelled elective surgeries and long wait lists for long-term care placement.

It is an oft-repeated axiom in Canadian provincial politics that parties don’t win re-election due to their handling of the health file. Parties certainly get voted out, however, if the public believes that they have mismanaged the health care system. With the 2017 Budget, the Liberals will be looking to address that risk head-on. Sources suggest that the Budget is squarely focused on investment in new health care programs and services to improve access to care. The ultimate goal is to take health care off the table as an area of political risk in 2018, and bolster the Liberal Party’s credibility as a “defender of public services”.

While full details of the budget plan will become clear on Thursday afternoon, stakeholders have been actively speculating for weeks about what to expect. Sources suggest that the system can expect movement in the following areas:

1. Health spending will inch up, perhaps signalling an end to the era of strict cost containment.

Over the past five years, as the government focused on returning the province to a balanced budget, health care spending growth was squeezed to just over 2% annually. As the government’s own Fiscal Accountability Office (FAO) has reported, such a level is insufficient to simply maintain access to care in the face of an aging population and growing demand for care. In fact, the FAO projects that spending would have to increase by an average of 5.2% annually for current standards to be maintained.

While no one expects the government to table a budget with over 5% health spending growth, there are suggestions that spending will finally inch back up over 3%. While this is incredibly modest in the historical context – the FAO points out that spending averaged 7.2% per year between 2005-06 and 2009-10 – it does, perhaps, signal the end to five years of singular focus on cost containment.

2. Hospitals will receive a base budget increase and targeted funding to address capacity problems.

Hospitals have been warning, loudly, for months that without targeted new investments they will be forced to close beds, cut back on elective procedures and reduce service levels. Already, the province has the fewest number of hospital beds per capita in the country. Premier Wynne has already signaled to the media that more funding is on the way for hospitals in the budget. The acute sector is anticipating both an increase in overall hospital base budgets and targeted investments to relieve over-crowding (particularly in the GTA) and ALC pressures in a number of communities.

3. There will be new investments in primary care.

In 2014, the Liberal Party platform included a commitment to ensure that every Ontarian has access to a family care provider. There is still more work to be done in this area. There are strong suggestions that Budget 2017 will include a host of measures to expand the capacity of inter-professional primary care teams like Family Health Teams (FHTs), Community Health Centres (CHCs) and Nurse Practitioner led clinics.

4. The Budget will reveal next step in the government’s strategy to shift care to the community.

The Health Accord that Ontario recently signed with the federal government commits an additional $2.3B over 10 years for investments in home care. While this is a drop in the bucket in terms of the overall health spend (around 0.5% boost in overall funding over that period), it is significant for the home and community sector. Just yesterday the government announced that it would be expanding support for caregivers an investing $20 million more per year in respite services. Budget 2017 is expected to provide more clarity on the government’s overall home and community investment strategy. The plan may also reveal details regarding the next step in the government’s plan to recruit and retain Personal Support Workers (PSWs).

5. The Budget may expand access to the Ontario public drug plan.

Ontario Health Minister Hoskins has advocated loudly and consistently for a national pharmacare program, but has done little to date to expand universal access at the provincial level. The Ontario NDP recently announced their plan to introduce a provincial pharmacare program if elected in 2018. This move appears to have caught Hoskins and the Liberal government off guard. While the 2017 budget is not expected to contain a universal pharmacare program to match the NDP pledge, there are rumblings that the government could make targeted investments to expand access in areas like cancer drugs for children. Some sources suggest that the government is also considering further cuts in generic drug pricing to support the listing of new medications of the provincial formulary. There are also rumours that the Budget will pave the way for an expanded role for pharmacists.

Of course, speculation and conjecture abounds prior to any budget. The real picture will become much clearer after 4 p.m. tomorrow when Ontario Finance Minister Charles Sousa formally tables the budget.

OPINION: Missed Opportunities to Encourage National Collaboration in Health Care

By Keltie Gale, Consultant at Santis Health

Despite Canada’s “universal” health care system, the care a patient receives can vary drastically between provinces. In order to achieve the equality of care that Canadians expect and deserve, provincial health systems need greater cooperation and collaboration and the federal government needs to incentivize these behaviours.

One prime opportunity for collaboration and cooperation is laid out in Dr. Danielle Martin’s recent book Better Now, Six Big Ideas To Improve Health Care for All Canadians. Big Idea Number Six speaks to the need to build systems that support the implementation of large-scale change. She points to the need for systems that will allow successful innovations to spread and scale in order to achieve better consistency across individual healthcare systems and between systems.

Acknowledging the challenges of implementation of new ideas, Dr. Martin points to three key success factors: (1) The system responsible for implementation must have the ability to track their implementation and to respond to the data; (2) they need to be bold enough to overcome entrenched interest; and (3) they need healthcare providers who are engaged in the process and who want to participate.

The Canadian Institute for Health Information (CIHI) annual report on wait times, released in March, is an example of the type of collaboration needed. CIHI can effectively collect and report this nationally standardized data because of provisions in the 2004 health accord that committed the provinces to working towards meeting wait times benchmarks for five priority procedures. In this case, CIHI is the mechanism that allows systems to track progress towards this goal.

Beyond these first five procedures, CIHI anticipates that it will have consistent reporting across the country on chemotherapy wait times for breast, colorectal and lung cancer by 2018, and six provinces have already standardized their reporting for wait times for diagnostic imaging. While these advances may seem minor, they represent growing alignment and any movement towards consistency across provinces should be seen as a success. Standardization of definitions, benchmarks and reporting can serve as the base for greater consistency of care.

Despite these modest signs of progress, the federal government has missed two major opportunities to take the bold steps needed to overcome entrenched interests and encourage greater national collaboration.

First, the recent health accord negotiations. When the negotiations among the health ministers broke down in December, the federal government pursued a different strategy. One by one, federal Minister of Health Jane Philpott and her team negotiated bilateral agreements with each province, save Manitoba with whom discussions are continuing as the province holds out for more money in key areas including healthcare in indigenous communities.

By negotiating and signing bilateral agreements with provinces individually, the Federal government missed an opportunity to rally the provinces around a common goal. Funding was directed to home care and mental health but the stipulations for this funding were negotiated province by province. While it is important to invest in these areas, the federal government could have created systems for better coordination and consistency across the country if these commitments had been made by the provinces collectively.

Second, Budget 2017. There is continued funding for CIHI and the Canadian Foundation for Healthcare Improvement along with investment in Health Canada, the Patented Medicine Prices Review Board (PMPRB), and the Canadian Agency for Drugs and Technologies in Health (CADTH). The government re-announced the specific funding agreed upon in the health accord negotiations for home care and mental health. Increased funding was directed to addressing the opioid crisis through the Canadian Drugs and Substances Strategy and its Opioid Action Plan.

While all of these federal initiatives are worthwhile, perhaps the budget is more notable for what is not there. More investments like that for the opioid crisis could have targeted other government health care priorities and helped build the necessary foundations for greater provincial collaboration.

Whether they live in the east or the west and a rural or urban area, Canadians should expect consistency in the care they receive. Agreements on wait times in 2004 were a start but Canada needs new, collective, broad, bold goals for better patient care and needs the provinces working together to achieve these goals. The federal government should have stepped up and used the health accord negotiations and the budget as platforms for working towards the equality we all expect and deserve in our healthcare systems.